Bring Back Our Girls

They must have run around the ground of the boarding school at the afternoon break. A girl giggling after another one tripped over. That girl might have cried, angry that she was giggled at. Finally, after the boring classes were over, they must have returned to the hostels, changed their clothes, had their snacks, and huddled in a class room to do their homework. They must have repeatedly looked at the wall clock, for the time when they would be allowed out of the room. As soon as the clock hit the time, they must have rushed out, only to be back to bed. In the quiet of the night, ceiling fans must have made whirring noise, fighting off the Nigerian summer. The girls must have been deep into sleep, dreaming perhaps.

What must it be like when they were woken up with noise, perhaps of gunfire, of crying and screaming friends? Bearded men brandishing machine guns in their hands must have grabbed their collars, pulled the girls out from their bunk beds, dragged them through the hallway while they were screaming and crying, loaded them in the truck like garbage bags and speeded through the dirt road, the truck jumping at the bumps, synced with the screams of terrified girls.

James Orbinski, who witnessed the horror of Rwandan genocide first hand as one of the only few doctors daring to care during the carnage writes, "...Over the last twenty years, I have struggled to understand how to respond to the suffering of others. I have come to know perhaps too well that only humans can be rationally cruel. Only humans can choose to sacrifice life in the name of some political end, and only humans can call such sacrifices into question...."

Boko Haram, a religious extremist group, kidnapped 276 girls from a Nigerian boarding school on the night of April 14-15. They are yet another testament to that rational cruelty. Hell needs not be imagined in various religious forms, the face of the evil ruling that hell can not be any crueler than of these kidnappers.

Rhetoric and Reality

(Note: This article got published in Republica with minor edits)

If a newly diagnosed diabetes patient came to see me at Patan Hospital’s general medicine clinic, I would perform several tests to ensure proper care. I would check hemoglobin A1c to assess her severity of diabetes, test her kidney function, evaluate if she is throwing out protein in urine, test if liver is functioning properly, and measure cholesterol levels in the blood. For this visit, she would pay NRS 25 for registration but about NRS 2310 for the basic minimal testing that she requires for appropriate diabetes care. After all this, she will have to go home with a bag of medications that comes with obvious cost. Patan Hospital might take a pride in saying that it charges a meager 25 rupees for a patient visit, but that is just a miniscule portion of the patient’s actual healthcare cost.

The point is, doctor’s fee is a rather small portion of a patient’s healthcare cost. Main drivers of cost are tests, medications and medical devices. It gets especially ugly if unnecessary tests are performed and medications prescribed. And it is no news that our healthcare providers are incentivized to do exactly that. We have heard of our doctors receiving “cuts” for sending lab tests, prescribing certain medications and even referring patients to certain institutions or providers.

So, if I were a deliberating patient, I would choose a doctor based on how unlikely she is to order unnecessary tests or medications while not missing what are absolutely essential. I would like her not to have incentives tied to prescriptions and lab orders. I would happily pay a much higher fee than NRS 25 if these were ensured, because that extra cost is just one unnecessary test away.

Lately, newspapers have reported that the Ministry of Health and Population (MoHP) is planning to cap and enforce doctor’s fee. Furthermore, Republica reports that even the prevailing fees are lower than the cap. Why is this non-issue taking a front row seat? One has to concede, the MoHP officials are either very disconnected from patients’ realities or they are plain and simple stupid.

Even this cursory exercise tells us, doctor’s fee is not the biggest determinant of a patient’s healthcare cost. Accordingly, there are multiple high-impact potential targets for cost control. We have to ask, how we can cut down the cost of lab and radiological testing. How we can reign in an unethical practice of ordering unnecessary tests and medications for financial incentives. How we can make equipment and medical devices more accessible and affordable. In addition, we need to ensure that the cost of medications is reasonable. While the remedies are not as obvious or simple, any genuine cost cutting effort cannot circumvent debating and deliberating these issues.

Furthermore, whatever is a patient’s financial means, what matters ultimately is the health outcome. We want to get better at any cost. We sell our cattle, our land, and our hard-earned savings to seek treatment. When we put so much trust in these medical interventions, what should matter most is that the healthcare system delivers to that trust. We are not just seeking a cheap treatment but also an effective treatment. Quality medical care is actually what we seek. Of course we would like to pay less for it.

Unfortunately, our public debate hardly acknowledges the intricacies of patients’ needs and the corresponding complexity of delivering to that demand. It is no surprise that rhetoric of  “free health care” is so rampant. Anyone pausing for a moment and thinking can realize that there can be no “free health care.” Delivering health care needs infrastructure, personnel, medications and equipment that come with a cost. The best we can do is pool our risks and minimize the cost for the victims of diseases and injuries. It would indeed serve us well if we root ourselves on practical realities than rhetoric. This proposal of capping a doctor’s fee is a rhetorical exercise disconnected from the real needs of our patients. It is far detached from the potential to bring down costs.

Finally, it is about time that we are done with doctor bashing. The reality is, after we pass past the dreamy aspirations of medical school, we doctors walk a blurred line amidst necessities, greed and professional obligations. Larger structural issues, checks and balances in the system largely determine how we behave in our daily practice. The society in general and government in particular has the responsibility to address these structural issues and ensure effective regulatory mechanism. Yes, some of us have crossed professional ethical boundaries and behaved poorly. Where are those regulatory processes? Where is our government to hold us in check at those instances? More importantly, we should not forget that numerous of our junior doctors work in the muggy air of crammed emergency rooms with air laden with tuberculosis, intensive care units with bare minimum support and protection, medical wards with surfaces laced with resistant bacteria and filth, deprived of sleep, and for exhaustive hours that is inconceivable in any other profession. They work at incredible personal risks. While their peers, who work in lucrative development jobs, writing reports and policies that never see the light of the day, come home with a six-figure salary, these doctors satisfy themselves with NRS 10,000 per month. Vilifying these doctors in the process of lumping doctors for rhetoric’s shake would be an utter injustice.

The problem at hand does not lend to a simplistic assessment and equally cavalier attitude of using the governmental power. People do have a choice in whether they want to see a doctor who charges NRS 1000. We don’t need our government to father us in making that choice. What we do want is help in ensuring that we are getting our money’s worth. That is and should be the purview of a democratic government. But it is also exactly where our government is utterly ineffective and our government officials have no wit, will or ability. For starters, our tax paid government officials would do much service in cutting cost if they even just focused on stocking low-priced quality medications, performing quality affordable lab tests, and consistent and reliable radiological tests at public institutions. Instead of coming up with these wacky ideas!

Kafal Sellers of Sworgadwari

Whose Kafal (Bayberry) should I buy?

Pardon my business acumen, but would it make more sense to spread out and sell? Wouldn't that increase your likelihood of making money for your own?

There is a certain innocence and cuteness in this group of Kafal sellers huddled together at the same place. With their baskets, wrapped in cloth, stashed with the produce from the wild. In their Kurthas, Surwals, Pachhyauras and Chappals.

These shy girls are huddled together, perhaps for each other's company. To survive strangers' exoticism. What will happen if they overcome this shyness and decide they want to make profits by competing with the other Kafal sellers? There's a certain harshness associated with this change. Cute innocence is trampled over by selfish motives. It feels as if something precious is lost in the process.

But that is a sentimental observation of an outside observer. Their act of Kafal trade is hardly cute. It is a chore you need to endure, fighting the glare and foreignness of strangers, in hopes of making some money that stoke vivid dreams. Cuteness and innocence are not what is celebrated here, not even remotely.

Mr. Maharjan

Amidst a patient visit I received a call on my cell phone. I ignored. But it rang again. So I excused myself from the patient and answered the call. On the other end was the daughter of a patient I used to see while working at a public hospital. The patient, Mr. Maharjan, had a long-standing diabetes. It had damaged his kidneys. The damage had now progressed to a stage where he was no longer able to throw out enough water and toxins through urine. As a result, fluid built up in his body. He had difficulty breathing and extreme weakness. They had brought him to this public hospital. He underwent emergent dialysis to remove fluid and toxins from his blood. 

"They have told us that we will be discharged. And they have asked us to find a place to have dialysis two times a week because there is no empty dialysis slot at the hospital. What are we to do?" she pleaded. With a shaken up voice, she continued, "we are poor, there is no way we can pay for dialysis unless we do it in government-subsidized place." "How can they just ask us to find a place when this is the only place we have been for all these years for his diabetes treatment?" she lamented. 

"I didn't know what to do and remembered you because you had treated us nicely at the hospital. Would you be able to help us?" she asked. 

What must it be like: to be drowning in your own water, gasping for breath, knowing that there is a way to relieve it, and yet being left alone to your own devices? As a society, we have actually already agreed to help out those who are in such needs. Government pays for dialysis at several government and non-governmental facilities. We tax payers, including Mr. Maharjan, are paying for this assistance. Multitudes of dialysis centers have popped up in Kathmandu. So why is Mr. Maharjan, amidst dire health condition, given a violent sentence of uncertainty?

Our doctors become quite animated about larger political, structural influences in health care systems. Many of the concerns are very legitimate and valid. And larger, systemic, political and structural issues do need to change for this health care system to be more accessible, just and fair. But many of these issues do not fall under our daily activities of patient care and doctoring. What we don't realize is that there are much more urgent issues directly under our power and capacity that we ignore. And to a ruthless extent. Which bureaucrat or politician will be able to understand the plight of Mr. Maharjan, real time, better than a doctor treating him? Yet, we choose to ignore to act. Rather, we take a delight in pronouncing dooms, telling this patient, good luck brother: find a place to get dialyzed on your own. Did they even consider what kind of ordeal it might be to the patient, a simple man without much education and means, to find a place where government offers subsidies for dialysis? Would it be easier for us who know hospitals and health care system to look around or it is best left to the patient? How can we just open the door and tell a gasping patient: out you go, do whatever you want? Is it even moral to dispose a patient to his means when we know that there is a solution, or at least an attempt could be made? 

I told her, "let's see what we can do." 

I first made a call to a friend who is a nephrologist at a medical school which houses a large subsidized dialysis facility. He told me there were no empty slots but asked to send the patient anyway to see if he could figure out a solution. I asked the daughter to go meet him. The best they could come up was an alternative way of dialyzing (called peritoneal dialysis) but it came with an upfront cost for tubings and devices to be connected to the belly, it was not an ideal option. So I searched out the contact for the chairman of a non-governmental organization which has been organizing dialysis facilities at multiple places. I told him the story and asked if he could help in any ways. He generously offered to do free dialysis at his private hospital. It was a big relief. We arranged an appointment for the patient at his clinic and I asked the daughter to go to that appointment. In the mean time, I wrote a letter to the chief of the service at the public hospital where the patient was admitted, and who I knew as a man who would go extra miles to help patients in need, detailing their plight and pleading, "you can very well imagine in what dire straits this patient is." In a few days, the chief of service from the hospital replied me saying that they were able to arrange dialysis within the hospital. 

Wow! That was it? There was not a magnanimous gulf separating possibility. But why did the patient have to undergo this distress of uncertainty while gasping for breath? 

The daughter called me to thank. 

After a few phone calls and few keystrokes of a computer, I will be able to get my good night sleep. But that can't be said of Mr. Maharjan and his daughter. Their ordeal has just begun  and it will end only with his death. 

Swami Ji

The hall was packed with people; the cleanly-dressed kind that have been sheltered from dust and soot that beclouds the majority. These were mostly doctors who had congregated to talk about spirituality. They were listening attentively. At the stage, Swami ji, adorned in yellow robes graced the throne. Throne, indeed! Long hair flowed out from his head, streaks of grey boosted elegance of his eminent beard. Energy was ebullient. Swami ji had captivated the audience. 

At the end of nearly an hour of his discourse, the message I gathered from Swami ji was: Thought is powerful. I felt that the discourse lacked any substance. It neither offered me any information about why recognizing thought as powerful was important nor it told me what next after recognizing the power of thought. It was an exercise of futility lacking in any direction or intent. It was as if someone spent an hour saying, "there is an apple in a tree."

But the Swami ji captivated the audience. He was a master at that. He had energy and charisma during the talk. Interjecting with rhetorical English statements during his monologue in Nepali, he convinced us that he was no traditional jogi. He would spit out a string of English names, who he informed us were philosophers. "Emerson knew that the East had already figured out two thousand years ago," he told us. "Big bang theory tells us that the world is going to end," he declared. He told us stories, simple ones in very easily understandable language, wrapped in humor, and we laughed heartily. "I consider myself philosopher and not a traditional jogi" he pronounced. He giggled wildly, laughed like a fool. Shouting at times, he toned down to a whisper like some musical exercise. He was a sight to behold.  

As he descended the stage and later walked out of the hall, he was surrounded by numerous young men from his organisation, clad in fluorescent jackets (like those of traffic police), people surrounded him, bowing, heaping praises, he was offered money and those young men in fluorescent jackets collected the money. Swami ji swaggered out the door smiling at a captivated audience, waving his hand, blessing perhaps. More young men started collecting many of the audio visual equipments that had been set up for Swami ji's discourse. It was a massive enterprise; the act of discourse. Even after the Swami ji left the premises, the young men lingered along with numerous video cameras and microphones, interviewing the attendees and taping the responses. 

There can be a discourse that transcends reasons: that of faith and things beyond reasoning. But that can be a coherent, meaningful discourse. There can be a discourse of matters using reasons and facts. His was neither of those. It was an entertaining talk by a charismatic man using pseudoscientific gibberish. 

And it had impressed the audience. It was terrifying that just the style of a substanceless  monologue had glossed over their critical reasoning. And it was furthermore terrifying that many in this audience claim the intellectual authority in this society. No wonder the Swami ji blankets Nepali TV stations in the mornings. 

Weather Forecast and Nepali Healthcare

Radio was our access to the larger world. In the silence of the night when crickets were chirping, in the dull sunny day punctuated by shouting of someone ploughing the fields using oxen driven ploughs, in the evenings when the sun started hiding behind the hill splashing gold in the horizon, or in the mornings on a clear day when mountains at distance glowed in glory, radio ruled. For us kids, music was the lure but we had to endure the news that the older ones prioritised. At the porch, we assembled around the radio. The news from "Radio Nepal" had a fixed format. At the end came the weather. They would quote the "Department of Hydrology and Meteorology" (DHM) and provide weather forecast for different regions of Nepal. Had you asked us kids at that time, we would have recited you the exact sequences of the regions they would forecast. But we would have told you that if the forecast predicted rains, it was almost a guarantee that there would be a sunshine. As I recall, it was hardly ever accurate. We trusted more our elders looking at the sky and predicting based on clouds than our trusted radio for the weather forecast. But the ritual continued unabated. It even continues to date.

How did this ritual come into place and why does it endure despite dismal track record of outcomes?

When I first went to North America, I was surprised by how much weather was common in social conversation. At the end of an interview someone would say, "tomorrow is going to be beautiful, you may want to explore the area." People planned their recreation based on weather forecasts, made sure that they had shovel in their cars if there was a prediction of snow in the evening. The weather forecasts were quite accurate. It was a completely different culture compared to what I was used to. We hardly ever planned things taking weather into account. In summers we were always ready with our rice seeds. We waited for the rain and when it poured down, we ran to our fields. Agrarian life was simple: it revolved around the crops and the activities dictated by whims of the weather. There was no point in planning out things but being prepared to comply with the dictates of the weather.

What must have transpired when the Nepali government decided to adopt the practice of forecasting weather back in 1962? Did someone who had learned about modern governance say, "we need this component of modern governance?" Or, perhaps, they looked at departments established in Indian government and say we need this too. Maybe foreign donors suggested establishing it.

How must they have first started the services? Did they get experts from outside who were used to doing this work regularly? Did they send personnel overseas to get the training? What kind of technologies they must have first imported? Were the initial weather forecasts accurate? Regardless, we know that in the nearly half a century of this exercise, the DHM's weather forecast has not been able to gather people's trust. These days, if we need any information on weather, we would rather turn on our Yahoo weather app than tune into Radio Nepal. Despite its futility and irrelevance DHM's persistence continues unperturbed.

It was an introduction of a new technology to a society where there was no real demand. Over the years it has degenerated to irrelevance. The outcomes are dismal. The whole process is now a bizarre exercise far away from the intent. The weather forecasts' such failure might be benign, but we have adopted many other technologies where the failures are not at all benign.

We lost 18 lives recently to an airplane accident in western Nepal. It is dizzying if we look at our aviation accident data. Every single year since 2010, we have had plane crash taking away lives (See here: 2010, 2011, 2012, 2013, 2014). And this is out of just about 20-30 events in the whole world (that includes incidents as well, not all crashes). European Union has blacklisted Nepali airlines and banned them from flying in Euro zone. Yet, our shamelessness and complacence is unperturbed. We have adopted technology but mixed ruthless incompetency to the operational process. The result is devastating. I doubt the folks running Nepal's aviation industry have any inkling of insight.

This same risky adoption of technology is rampant in medical field that I am part of. In Nepali market-place you can find all the fancy new developments in global medical technology. For some of the medications which required crossing some hoops in North America, you find them here without much trouble. It is very easy to spot a neurosurgeon or for that matter any "specialist" in any field . A single person will claim himself to be an internist, gastroenterologist and endocrinologist without any structured training. With zero (0) fully-trained endocrinologist, a government institution runs an endocrinology fellowship. These poorly-trained "specialists" equipped with scopes, scalpels, injections and drugs experiment on lives; groping in the dark, unsupervised, unaware of how those trades/skills are supposed to be actually used. Unfortunately, there is no bang and fire of airplane crash in these nonchalances. Just voiceless and silent lost lives, sufferings, and hardships. Those who are so eager to adopt things that they don't have much idea about argue that it is a transition for the sake of future. But, in their recklessness, what they should realise is that poorly adopted technologies or authorities (in certain specialised skills) have grave consequences in medical field. Just like aviation industry, Nepali medical field has a lot of soul-searching in order. It is already a terrifying territory now. 

Arundhati Roy

"The things I've needed to say directly, I've said already. Now I feel like I would be repeating myself with different details," says Arundhati Roy in an article in NYT piece on her. I dearly hope and wish that Ms. Roy is not swayed away from the details by the apparent reiteration. We will be deprived of unparalleled clear narratives that has come with great personal risks to Ms. Roy, as the article makes it quite obvious.

"Titillating," is the word I attribute to the feelings her fiction "God of Small Things," had incited when I first read the book. The softness of her language cuddled a story that was not so kind. The woman so tender to her story has not been very delicate in her diagnoses of social ills ravaging India and in some cases the world. In the process, she has been a target, an outcast. Speaking truth to the power is a risky venture in these shores. The reactions tend to be visceral, personal, and defiant of logic and reasoning. But I hope we will continue to hear from Ms. Roy.